Provider Demographics
NPI:1215941158
Name:CLARKE, AIDAN M (MD)
Entity type:Individual
Prefix:
First Name:AIDAN
Middle Name:M
Last Name:CLARKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W MONTECITO WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1227
Mailing Address - Country:US
Mailing Address - Phone:619-564-7463
Mailing Address - Fax:619-564-7463
Practice Address - Street 1:1725 W MONTECITO WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-1227
Practice Address - Country:US
Practice Address - Phone:619-210-9291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG642922083A0300X, 207LP2900X, 2081P2900X
IL036-114565208VP0014X
MO20040325242081P2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G642920OtherBLUE SHIELD
IL036114565Medicaid
00G642920OtherBLUE SHIELD
E98751Medicare UPIN
ILK23129Medicare PIN
IL036114565Medicaid
CAP00772562Medicare PIN